What Do We Call a Hospitalist Without a Hospital?

Joshua Niebruegge , MD

Medical Director, Memorial Hospital

Published August 17, 2020

Reimagining the Future of Inpatient Care Delivery

COVID-19 has reshaped the way acute care is delivered, including what we think of as “inpatient” care. From managing surges to driving patients out of the hospital, the pandemic has shone a light on the important role hospitalists play. As we remake care delivery for the future, Vituity hospitalists are leading the design of new roles for inpatient physicians, with the backing and support of an organization dedicated to patient-centered care.

In early March, my colleague Behfar Dianati, MD, hospitalist medical director at a small Midwestern practice, admitted a patient with apparent flu. A week later, he, his wife, and their two children were sick with COVID-19. Dr. Dianati’s wife experienced respiratory failure and was intubated in the ICU for ten days, and he was quarantined at home for two weeks. This was in the very early stages of the COVID-19 pandemic, and several weeks before a national emergency was declared.

Meanwhile, at the hospital, Dr. Dianati’s team was short-staffed and struggling after a second hospitalist came down with COVID-19. From his spare bedroom, Dianati worked tirelessly with the hospital administration and nursing leadership to implement a virtual rounding program that allowed him to manage the COVID-19 ward from home singlehandedly. He even donated his iPad to the cause, which the staff promptly named after him by frequently saying, “Bring me Dr. Dianati.”

As a fellow hospitalist, I much admire Dr. Dianati’s dedication to his work and patients under extremely difficult circumstances. What’s more, I believe his virtual rounding solution illustrates the direction hospital medicine must be headed.

In the COVID-19 era, care will no longer revolve around the hospital except for those most critically ill. It’s imperative that we meet patients where and when they need us. In this article, I share some thoughts on how our specialty is evolving and how Vituity is expertly positioned to support hospitals and physicians through this tumultuous time.

future of acute care

What a Difference a Pandemic Makes in Hospital Medicine

COVID-19 has proved to be healthcare’s great disruptor. We are now living through a period of significant disequilibrium leading to rapid systemic transformation.

Before the pandemic, I’d been working with my hospitalist teams to implement some basic telehealth applications. At every turn, we hit obstacles from regulations to credentialing and reimbursement. While we soldiered forward, enthusiasm seemed lukewarm.

As a result, many of our hospital medicine teams now deliver some or all care virtually. Virtual rounds and consults protect staff, preserve personal protective equipment (PPE), and allow hospitalists to care for patients from anywhere.

COVID-19 is also shifting the acute care paradigm beyond hospital walls. For example, to increase hospital capacity in California's Central Valley, Vituity and Adventist Health partnered to establish the Hospital@Home program. Stable patients with appropriate diagnoses are transported home, where they are managed virtually by the hospitalist team. They also receive in-person visits from mobile nursing teams and ancillary services units. If concerns arise, patients have access to a virtual call button monitored remotely by a registered nurse.

While Hospital@Home is still in its early stages, we see every indication that it provides high-quality care while also acting as a major patient satisfier.

The Importance of Patient-Centered Care

As the pandemic wears on, it’s becoming increasingly clear that nervous patients are forgoing needed care. Acute care visits decreased sharply during the initial shutdown and have yet to fully rebound — even for emergencies like heart attack and stroke. When patients do present to the hospital, their conditions are often exacerbated due to care delays.

Given the stakes, it’s imperative that health systems shift to more flexible care delivery models that meet patients where they are. In practice, this means expending telehealth access and even providing a “virtual front door” that navigates patients to the most appropriate care setting (telehealth, urgent care, ED, etc.). This shift impacts hospital medicine as well, as patients can be discharged from the ED to their homes for what used to “inpatient” monitoring and treatment.

Caring for patients also means looking out for the physical and emotional safety of clinicians. Even before the pandemic, 42% of physicians reported burnout symptoms. The arrival of COVID brought new worries, such as spreading COVID to family members. Among the benefits of virtual hospital care are the reduced physical exposure to possibly contagious patients and less dependence on often limited supplies of personal protective equipment (PPE).

Clinical Leadership Will Drive the Future

While it’s interesting to imagine the future of hospital medicine, the fate of our specialty ultimately lies in the hands of empowered and engaged physicians. Physicians represent our closest connection to patients and are best positioned to identify both pain points and solutions that transform hospital care for the better.

To expand on the concept of virtual care, health systems are increasingly utilizing technology to not only treat patients in their homes but leverage a national workforce of providers so that we no longer need everyone in the same community. We will be able to reach areas that have historically been too difficult to recruit by enabling providers to live where they want yet treat patients locally. This expands patient access to care, particularly in underserved communities. And this flexibility for providers means that patients in more rural areas can have access to specialist providers without having to travel far distances.

In addition to this shift outside the hospital and the increasing use of technology such as telemedicine, hospital medicine needs to transform our business model. As hospital margins continue to shrink, we need to be open to alternative payment models and staffing structures that focus on quality of care as well as cost of care reduction. At Vituity, we are on the cutting edge of this trend and will continue to lead this transformation into the future. One way we are changing this paradigm is by utilizing advanced providers and registered nurses to decrease the busy-work burden currently being placed on physicians while also reducing costs.

Thinking further out, I can envision a future when hospitalists leverage the capabilities of artificial intelligence (AI) to aid with data entry for electronic health records (EHRs). This would then open up hospitalists’ time and resources to be a strategic reviewer and interpreter of data and use their findings to help influence the management of conditions, patients, and care teams. Our future state is limited only in how wedded we remain to today’s definition and role of a hospitalist.

Given the mountain of pressures weighing down physicians (many of which predated COVID-19), it’s imperative for healthcare leaders to work closely with their medical teams to effect meaningful and sustainable change. Here are some practical action steps to get the ball rolling.

1. Create a Culture of Caring

Great cultures embrace the human as well as the clinical dimensions of medical practice. They acknowledge the unique physical, emotional, and spiritual demands of our specialty (especially in a disaster) and provide the support and resources providers need to be effective. Viewing patient care as our shared goal inspires us to look out for one another and lift up our colleagues during difficult times.

At Vituity, our “culture of caring” means coming together like family in times of crisis. When a colleague or practice is in need, hospitalist partners travel from across the country to provide support and relief. We’re now scaling these efforts by mobilizing regional telehealth teams that can augment and relieve front-line providers in the event of a COVID surge.

2. Engage Your Hospitalists

In these difficult times, physicians represent their hospitals’ greatest innovation assets. The rapidly evolving pandemic requires fast, flexible, and innovative responses that are best led by front-line physicians. Healthcare leaders should, therefore, consider how they can invite physicians into the change process as co-creators.

Our experience at Vituity suggests that highly engaged providers who feel valued by hospital leadership tend to be the most committed solution providers, as illustrated by Diamati’s story. Sick, quarantined, and cut off from his critically ill wife, he still felt an extraordinary sense of responsibility to his hospital, colleagues, and patients. His quick, thoughtful actions allowed the hospital to remain open throughout the initial COVID surge — and likely saved lives.

3. Consider the Benefits of Physician Ownership

The pandemic has exposed the cracks in the physician employment trend. As I write this, hospitals are laying off physician employees in record numbers, because they can no longer guarantee their salaries. Ownership benefits both hospitals and physicians. Physician-owned groups are well-positioned to control their costs, which insulates their hospital partners in volatile markets. At the same time, physician owners know that while take-home pay may fluctuate somewhat with the economy, their jobs remain secure. In fact, Vituity has recruited many hospitalists recently laid off by hospitals and corporate employers.

“By rising to the occasion through courage, innovation, and compassion, hospitalists will write the story of 21st-century healthcare.”

Joshua Niebruegge, MD

A Doorway to Healthcare Transformation

In these uncertain times, one thing hospitalists can count on is demand. The direct impact of COVID-19 will be with us for many more months, if not years. By rising to the occasion through courage, innovation, and compassion, hospitalists will write the story of 21st-century healthcare.

COVID-19 has challenged hospitals and providers more than any other healthcare crisis in our lifetimes. At the same time, it has opened the door for sweeping transformation. I am confident that many of the acute care improvements we implement today will outlive COVID.

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